MEDICARE: MITZI CAROLINA FOGG R.N., M.S.N., F.N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	633049	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881802148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITZI CAROLINA FOGG R.N., M.S.N., F.N.P.

Provider Business Mailing Address
First Line	:	3538 SKILLMAN LN
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94952-1208
Country	:	US
Telephone Number	:	415-827-0767
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 E COTATI AVE
Second Line	:
City	:	ROHNERT PARK
State	:	CA
Zip	:	94928-3609
Country	:	US
Telephone Number	:	707-664-2921
Fax Number	:	707-664-2925

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	10/25/2022

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